Healthcare Provider Details

I. General information

NPI: 1033426820
Provider Name (Legal Business Name): SAINT JUDE HOSPICE-MISSISSIPPI,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 03/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3166 W JACKSON ST SUITE 2
TUPELO MS
38801-7154
US

IV. Provider business mailing address

3166 W JACKSON ST SUITE 2
TUPELO MS
38801-7154
US

V. Phone/Fax

Practice location:
  • Phone: 662-841-5907
  • Fax: 662-841-5910
Mailing address:
  • Phone: 662-841-5907
  • Fax: 662-841-5910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number094
License Number StateMS

VIII. Authorized Official

Name: MR. BRIAN M. WEGENER
Title or Position: CHIEF FINANCIAL OFFICER
Credential: CPA
Phone: 515-221-9155